The Prisoner of Stress

What does anxiety mean?

Scott Stossel has tried almost every treatment available for his anxiety, from drugs to yoga. Nothing has worked.Credit Illustration by Miguel Gallardo

People don’t ordinarily self-medicate by writing a book, but “My Age of Anxiety” (Knopf) is an attempt at recovery by a man whom modern psychiatry has failed. The man is Scott Stossel, a successful journalist (he is currently the editor of The Atlantic), now in his forties, who has suffered all his life from an acute anxiety disorder. When he was a child, he had terrible separation anxiety; as he grew up, he acquired phobias about public speaking, flying, fainting, heights, closed spaces, germs, vomiting, and cheese. Many people have an aversion to those things (cheese excepted), and, given the option, go out of their way to avoid them. But, faced with the prospect of a plane trip or a speaking engagement or sometimes even a squash match or a meeting at the office, Stossel experiences full-blown panic: insomnia, sweating, vertigo, stomach pains, and loss of control of his bowels. The sight of an unfamiliar pimple can send him down a bottomless chute of dread. He nearly passed out at his own wedding.

Stossel has been in therapy since he was ten, and he has consumed a whole medicine cabinet of psychopharmaceuticals—Thorazine, Nardil, Prozac, Zoloft, Paxil, Wellbutrin, Valium, Librium, Xanax, Klonopin, and a dozen more—not to mention alcohol. A few drugs and drug cocktails have tempered his symptoms, but the respite never lasted long. His current therapist encouraged him to write this book, and he says he has taken the advice in the hope that “by tunneling into my anxiety . . . I can also tunnel out the other side.”

“My Age of Anxiety” is not a memoir. Stossel tells us things about his parents, his marriage, and his children, but only things that are relevant to what he calls, after a famous remark of Freud’s, “the ‘riddle’ of anxiety.” The same is true of what he tells us about himself. He appears simply as a sufferer. Most of his book is a scholarly exploration of the history of anxiety and a journalistic account of the present state of medical knowledge. It’s intelligent, interesting, and well written, but the subject of anxiety is a mess, and the book, intentionally or not, is an accurate representation of its subject.

It doesn’t solve the riddle, either, but that’s not Stossel’s fault. It’s because anxiety of the kind he is afflicted with is not a riddle. It’s an illness. There is therefore nothing, except in the medical sense, to solve. That’s not what Stossel wants to believe, though. He has an idea that more is at stake. He thinks that there is a metaphysics of anxiety. “To grapple with and understand anxiety,” he says, “is, in some sense, to grapple with and understand the human condition.”

Many people have made this claim, but it can mean different things. It can mean that human beings are creatures who care about the future, and so hoping for good outcomes and worrying about bad ones comes with membership in the species. This is, roughly, the existentialist view. Sartre thought that we feel anxiety when we appreciate the responsibility we bear whenever we act—when we realize that, ultimately, there is nothing out there, including the ethical systems we are born into, that backs up our choices, and nothing that guarantees that they will be the right ones. Dogs and cats, presumably, do not know this feeling. Anxiety is the price tag on human freedom.

The idea that anxiety is central to the human condition can also mean that our mental life is characterized by psychic conflict, and anxiety is the symptom of that conflict. This is, roughly, the psychoanalytic view. It’s what Freud meant when, in 1917 (not, as Stossel has it, 1933), he called anxiety “a riddle whose solution would be bound to throw a flood of light on our whole mental existence.” Anxiety is the common feature of all neuroses. Feeling anxious is what makes people seek psychiatric help. It’s a signal that unconscious drives are in conflict—that (as Freud believed in 1917) the ego is repressing a libidinal impulse. We’re not aware of the conflict itself—we’re not aware that we have a repressed desire—but we are aware of our anxiety. That’s what makes it the key to understanding what’s going on inside our heads.

Anxiety plays a big role in other accounts of the human condition, too. In theology, anxiety has been associated with the concepts of conscience, guilt, and original sin. Reinhold Niebuhr called anxiety “the inevitable spiritual state of man.” In evolutionary psychology, anxiety is usually explained as part of the “fight or flight” reflex that gets triggered in the presence of danger. The reflex is naturally selected for: organisms that lack it might fall off a cliff or get crushed by a mastodon, because their physiologies failed to warn them of a threat to their survival. And, in some schools of sociology and cultural theory, anxiety is interpreted as a reaction to the stress and uncertainty of modern life. It’s a natural response to unnatural conditions. It’s how we know that the world is headed in a bad direction.

This is the hand the student of anxiety is dealt. But he can pick only one card. The existentialist’s anxiety, the psychoanalyst’s anxiety, and the anxieties of theologians, sociologists, and evolutionary psychologists have almost nothing to do with one another. They are not even compatible with one another. If anxiety is a product of modern life, then it is not the result of unconscious drives. If it’s the result of unconscious drives, then it is not a sign of our existential awareness of the nature of freedom. It can’t be entirely conscious, unconscious, socially conditioned, and hard-wired at the same time. The most we can say is that a mood that almost everyone experiences has featured prominently in various theories of human life and the world we inhabit.

The term itself is a catchall. People describe themselves as excited, nervous, apprehensive, tense, stressed out, bugged, worried, panicky, vapor-locked, scared shitless, sick to their stomach, and feeling like they’re gonna die. Each of these moods is arguably a form of anxiety, but they are experienced as very different affective states. All sorts of events in life make us feel keyed up. The brain states may be similar, but the adrenaline rush we experience when we mount the stage to accept the Oscar for Best Actress does not seem to have much in common with a cheese phobia.

What makes the business even more confusing is that anxiety is hard to distinguish clinically from depression. We picture anxious people as hyper and overreactive, and depressed people as lethargic and indifferent. But depression, too, can be understood as a response to a perceived or imagined threat, and antidepressants like Prozac and Effexor also alleviate anxiety. Medically, anxiety and depression appear to be two related symptom clusters arising from (or causing) the same underlying neurological condition. So melancholy, grief, abulia, Weltschmerz, loss of libido, thoughts of suicide, and, presumably, a host of other symptoms associated with depression, like anger and irritability, all get lumped into the category of anxiety.

This gives Stossel a lot to sort out. He is an honest guide. He is committed to thinking through the philosophical, scientific, and human implications of a mood that appears to be universal (though people who live in underdeveloped countries seem to be less anxious) and that has attracted the attention of writers from Aristotle and Robert Burton (the seventeenth-century author of “The Anatomy of Melancholy”) to Søren Kierkegaard and William James. One of the best things about him is that he’s generally agnostic toward the theories and treatments he examines. He sees the possibilities in everything.

He is stronger on the science than he is on the intellectual history. Medical research and psychiatric treatments belong to a world that Stossel knows intimately as a patient, and researching the book must have been a way for him to try to reconcile a lot of contradictory professional advice. For he has spent almost his entire life bouncing around on the roulette wheel of contemporary psychiatry. Calling him a victim would be melodramatic; however wretched he feels on the inside, he’s a high-functioning neurotic, and it’s not obvious what the right treatment for him is. But his story is a good window on the crazy history of the field.

It was in the nineteen-forties that anxiety became the multipurpose power term it is today. Stossel’s title is an echo of the title of W. H. Auden’s book-length poem “The Age of Anxiety,” which was published in 1947. Auden called the poem “a baroque eclogue,” and it is dense and difficult. As one of his editors, Alan Jacobs, put it, the work is “extraordinarily famous for a book so little read; or, extraordinarily little read for a book so famous.”

The title struck a nerve, though. The book won the Pulitzer Prize for Poetry in 1948; Leonard Bernstein composed a symphony based on it in 1949; and Jerome Robbins composed a ballet based on Bernstein’s symphony in 1950. It went through several printings. Everyone thought that Auden had given the postwar era its name.

Auden didn’t take the concept of anxiety from Freud. He took it from Kierkegaard. As the historian George Cotkin showed in “Existential America,” Kierkegaard’s influence on postwar American intellectual life was enormous, much greater, in the beginning, than Sartre’s. Between 1936 and 1944, some twenty volumes of Kierkegaard’s writings appeared in new English translations, a mammoth project overseen by an Episcopalian minister from Philadelphia named Walter Lowrie, who had learned Danish at the age of sixty-four in order to read Kierkegaard in the original.

All sorts were drawn to him. Whittaker Chambers, the ex-Communist who accused Alger Hiss of being a spy, was a Kierkegaardian. So was Peter Drucker, the father of modern management theory. The Abstract Expressionist painters Barnett Newman and Mark Rothko were obsessed with Kierkegaard. Arthur Schlesinger, Jr., mentioned him in “The Vital Center,” his manifesto about liberalism and totalitarianism, in 1949. He is a prominent figure in the theologian Paul Tillich’s influential book “The Courage to Be,” published in 1952. “Today it has become almost a truism to call our time an ‘age of anxiety,’ ” Tillich wrote.

Anxiety in Kierkegaard is a kind of vertigo—“the dizziness of freedom,” he calls it. It involves a recognition of one’s finitude and one’s sinfulness, and is a stage on the road to faith in God. This is pretty far from Freud (who was an atheist). Nevertheless, in the nineteen-fifties Kierkegaard’s notion of anxiety and Freud’s got merged.

Freud had a low opinion of the United States, but the rise of Hitler forced European psychoanalysts abroad, and most of them ended up in London and New York. (Freud himself barely escaped the Nazis. He left Vienna for London in 1938, after his daughter Anna was interrogated by the Gestapo. Four of his sisters died in the camps.) The émigrés—people like Bruno Bettelheim, Erich Fromm, Heinz Hartmann, Karen Horney, Heinz Kohut, and Otto Fenichel—observed Freudian doctrine with varying degrees of orthodoxy. (Orthodoxy mattered to Freud: he was continually excommunicating wayward disciples.) They adapted quickly to the New World; they comported themselves with Old World authority; and their ideas were adopted and engaged with by prominent American psychologists and psychiatrists.

Most practicing psychiatrists in the United States were not psychoanalysts, but they used Freudian assumptions. The first edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1952, was thoroughly psychoanalytic, and psychoanalysis was the form of psychiatry taught in American medical schools in the nineteen-fifties. Anxiety was its central concept. The D.S.M. called it “the chief characteristic” of all neuroses.

The vogue for Kierkegaard and the stature of Freud was an invitation to a conceptual wedding. People in the psychiatric community began associating Kierkegaard and Freud in the late nineteen-forties, and, in 1950, the American psychologist Rollo May published “The Meaning of Anxiety,” in which he brought Kierkegaard and other philosophers together with psychoanalysis.

May had some differences with Freud, one of which was shared by almost every other psychologist and psychiatrist working in the United States after the war. This was the belief that neuroses can be responses to social conditions. Freud hated the idea that neuroses are responses to conditions, because he hated the idea that social reform can make people happier. That’s what “Civilization and Its Discontents” is all about.

But making people happier is what America is all about, and for Freudianism to succeed here it had to be able to connect people’s mood disorders to their circumstances. Gas chambers, atomic bombs, the death of God, the pressure to succeed, the threat of totalitarianism, the loss of faith in reason (May’s candidate)—you name it. The twentieth century is a nightmare. Anxiety became a master concept. It was the disease of modern life.

The notion that disorders such as anxiety and depression are caused by stuff out there in the environment, that they are like the diseases we catch from germs and viruses and are not symptoms of internal conflicts, was important to the success of an industry that was poised to take off: Big Pharma. Stossel tells the story well—how a Czechoslovakian émigré named Frank Berger discovered by chance a chemical, mephenesin, that relaxes the muscles, and how a company called Carter synthesized that chemical and sold it as Miltown, an anxiolytic that became the first pharmaceutical blockbuster. Miltown spawned Equanil, and they were followed, in the nineteen-sixties, by Valium and Librium—all of them mega-sellers, the Prozacs and Paxils of their day.

The drugs were initially marketed to high-functioning people as tranquillizers, pills necessary for coping with the special demands of life in the fast lane. Around the time that Miltown was taking off, Hans Selye, a Hungarian émigré working in Canada, coined the term “stressor” (as he had earlier coined the psychological term “stress”). His book “The Stress of Life,” published in 1956, announced (among other things) the important news that stress is a reaction to good things that happen to us as well as bad ones. “The stress mechanism,” Selye explained, “and, indeed, nature in general, is quite indifferent to human concepts of good or bad.” Getting a big promotion is as stressful, physiologically, as getting laid off. We really need those pills!

All of this should have made Freudian theory obsolete. But, for a long time, no one seemed to notice. No one pointed out that, if the drugs worked, then maybe mood disorders have a neurochemical basis, and anxiety is probably not (as Freud had come to believe) about things like the fear of castration. And if it’s a neurological disorder, something to do with brain amines, then maybe there’s no point spending years lying on a couch free-associating about last night’s dream when you can stop the suffering by popping a pill.

It wasn’t until 1965, when the American psychiatrist Joseph Schildkraut published a paper called “The Catecholamine Hypothesis of Affective Disorders,” proposing the amine theory of depression, that this seems to have sunk in. And it wasn’t until the third edition of the D.S.M., published in 1980, that Freudian theory was finally dislodged from its place at the center of American psychiatry. Talk therapy didn’t go away—people like to talk about their troubles, and many feel better for it—but, medically, it took a back seat to psychopharmacology. It lost its claim to science.

Not just Stossel the author but Stossel the mental patient is the heir to this exciting but not terribly edifying history. His first psychiatrist, whom he started seeing when he was ten, was trained as a Freudian. Stossel refers to him as Dr. L. Dr. L. was not hostile to medication, but he believed in repression, the Oedipus complex, and the like. He administered Rorschach tests and had Stossel free-associate in order to get access to the subconscious root of his problems. Later on, he tried hypnotism, eye-movement desensitizing and reprocessing, inner-child therapy, energy systems therapy, and internal family systems therapy. “I was the beneficiary, or possibly the victim, of seemingly every passing trend in psychotherapy and psychopharmacology,” Stossel says.

When Stossel was twenty-five, his parents began a process that led to their divorce. Dr. L. took Stossel’s father on as a patient, and, even more amazing, he used his sessions with Stossel to discuss the father. (Dr. L. and his wife were also seeing Stossel’s father and mother in couples therapy.) The father, an alcoholic and an emotionally distant man, was triumphantly “cured” in less than two years—which made Stossel feel, he says, “like a schoolchild whose younger sibling has just sped past him in the accelerated class.”

After twenty-five years, Stossel changed psychiatrists. He is now with Dr. W., who appears to be a humanist-existentialist practitioner—a school of psychiatry of which Rollo May is one of the founders. A big question in the treatment of mood disorders is how seriously to take the patient’s own reasons for feeling anxious or depressed. If the disorder is a neurochemical disturbance, then the patient’s stories about his or her problems may just be the mood talking. If you can make the mood disappear, then the problems will disappear. But those stories aren’t completely made up. Dr. W.’s assumption, as Stossel explains it, is that although cheese and vomiting are not life-threatening, there is a traumatic or psychically wounding event that underlies anxiety about them. As Stossel puts it, the theory is that anxiety arises from “failed efforts to resolve basic existential dilemmas.” The goal of therapy is to address those dilemmas by getting back to the original hurt.

Dr. W. is skeptical of biological explanations for mental disorders (like genes) and of chemical cures (that is, drugs), but he has let his patient pursue pharmacological treatments and other strategies. Stossel seems to have undergone almost every type of treatment out there, with the exception of electroconvulsive therapy. These include, in addition to the therapies tried by Dr. L., family therapy, group therapy, cognitive behavioral therapy, rational emotive therapy, acceptance and commitment therapy, meditation, role-playing, interoceptive exposure therapy, supportive-expressive therapy, self-help workbooks, massage therapy, prayer, acupuncture, yoga, and Stoic philosophy. And, now, writing a book.

How effective were these trials? Stossel’s description of his life during the time he was writing the chapter on drugs can serve as a commentary: “Many nights I would begin the evening fueled by caffeine and nicotine, which I needed to propel me out of torpor and hopelessness—only to overshoot into quaking, quivering anxiety. Thoughts racing, hand shaking, I would end the evening taking a Klonopin and then perhaps a Xanax and drinking a Scotch (and then another and another) to settle down. This is not healthy.” That’s an understatement.

One way in which anxiety differs from depression is that anxious people are often not dysfunctional. William Styron wasn’t able to write “Darkness Visible” when he was clinically depressed; Andrew Solomon had to get over his depression to be able to write his marvellous book “The Noonday Demon.” Though Stossel’s disorder must have made progress painful, he does not appear to have been in remission when he wrote “My Age of Anxiety.”

Whether or not this has something to do with the beneficial aspects of anxiety—it focusses the mind and prepares the body for action (in extreme cases, by evacuating the bowels)—there are many successful people who, like Stossel, have managed to cope with serious phobias and nervous disorders. He discusses a number of them. Charles Darwin suffered from a social anxiety that frequently made it impossible for him to leave his house. Laurence Olivier and Hugh Grant had stagefright. (Grant has said more than once that he was going to stop making movies.) Richard Burton could not bear to be in a room where there was honey. Joan Baez and Matt Lauer have come out as emetophobes: they share Stossel’s dread of vomiting. On the other hand, Bill Russell, the star center of the Boston Celtics, and one of the most dominant athletes in the era of professional sports, vomited before almost every game he played in. On nights he didn’t, his teammates worried that they would lose.

Nerves are a mystery. Some people seem to have none. We admire these people for their pluck, but, really, they are just born lucky. Other people have agoraphobia (fear of public spaces) but are courageous in battle. Most of us have minor performance and social anxieties that stop as soon as we get in front of the microphone or realize that the strangers at the party are no less uninteresting than we are. Our brain shuts off the release of cortisol (the stress hormone associated with the fight-or-flight reflex) and other chemicals that were making us feel anxious. We have evacuated our psychic bowels. We are in the present and in control. We feel good—or, at least, we no longer feel like we’d rather be dead.

In normal life, anxiety has content. It’s not merely a somatic reflex. Bill Russell’s anxiety tells us something we otherwise wouldn’t know about Bill Russell. It tells us how he felt about what he did for a living. Anxiety like Russell’s is triggered by a conscious thought about a present or future circumstance. It is scary to compete in public against talented people who would love nothing more than to make you fail, just as it’s scary to be in an airplane in a thunderstorm or to have a monster under your bed. Those things are scary because they’re dangerous—minimally, to our egos, or, maximally, to our chances of survival. Anxiety protects the organism. In the monster-under-the-bed cases, we can be helped with talk therapy or cognitive behavioral therapy, which teaches patients mechanisms for getting control over anxiety-producing trains of thought.

What appears to happen in the brains of people with acute anxiety disorder is what Peter Kramer, the author of “Listening to Prozac,” calls the “stuck switch” problem. The brain fails to shut down the release of stress hormones, and the body keeps pumping them out. The danger is that the overproduction will eventually damage the brain, so that, as Kramer puts it, “temporary injuries become permanent.” Solomon quotes Robert Post, formerly at the National Institute of Mental Health: “If you have too many episodes, it changes your biochemistry for the bad, possibly permanently. At that point, many therapists are still looking in completely the wrong direction. If the episode now occurs on automatic, what good is it to worry about the stressor that kicked off the original process? It’s just too late for that.” Stossel says that he worries about the harm to his brain. It seems a reasonable thing to worry about.

“To say that my anxiety is reducible to the ions in my amygdala”—the home of the fight-or-flight reflex—“is as limiting as saying that my personality or my soul is reducible to the molecules that make up my brain cells or to the genes that underwrote them,” Stossel writes. He is being true to the sayings of Dr. W., and to the beliefs of many people who distrust the medicalization of mood disorders. Still, at the end of his book, Stossel makes a good case that his problem is, at bottom, genetic. He lists, in addition to his angry and detached father and his overprotective mother, many relatives with clinical levels of anxiety and depression, including a great-grandfather, a Harvard dean who ended up in and out of McLean Hospital, suffering from chronic and debilitating depression. Sometimes it just is the biology.

But (to get back to the human-condition thing) being human is all about coping with our biology. As a species, we lucked out: natural selection gave us minds, and that freed us from the prison of biological determinism. We can put our genetic assets to positive account if and as we choose, and sometimes we have to try to do the same thing with our genetic deficits. As this man has bravely and admirably done. ♦

Louis Menand has contributed to The New Yorker since 1991, and has been a staff writer since 2001.